1073874970 NPI number — NEURORESCUE, A PROFESSIONAL MEDICAL

Table of content: (NPI 1073874970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073874970 NPI number — NEURORESCUE, A PROFESSIONAL MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEURORESCUE, A PROFESSIONAL MEDICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHERN CALIFORNIA NEURORESCUE SPECIALISTS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073874970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 COLLIER CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92782-1525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-443-0011
Provider Business Mailing Address Fax Number:
949-284-0604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18111 BROOKHURST ST
Provider Second Line Business Practice Location Address:
5800
Provider Business Practice Location Address City Name:
FOUNTAIN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92708-6728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-443-0011
Provider Business Practice Location Address Fax Number:
949-284-0604
Provider Enumeration Date:
06/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
MIAN
Authorized Official Middle Name:
MOHSIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-443-0011

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X , with the licence number:  A66315 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: A66315 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: A66315 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0400X , with the licence number: A66315 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084V0102X , with the licence number: A66315 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X , with the licence number: A66315 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: A66315 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: A66315 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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